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HomeMy WebLinkAboutbld-23-002734 Ln1 / /- 1 b-Z off•Y.R Office Use Only, s., � 0 Permit# r� _ i S tJ Amount U 44`:. `'` Permit expires 180 days from issue date 60-a3 _mg 73q C4C10,0 [ k( EXPRESS BUILDING PERMIT APPLICATI t r TOWN OF YARMOUTH i V E D Yarmouth Building Department 1146 Route 28 NOV 16 2022 South Yarmouth, MA 02664 _ (508) 398-2231 Ext. 1261 neUILDING DEPARTMENT CONSTRUCTION ADDRESS: 29 (G p+-4.'n ax-f 0 .i.M O {)I 1402 6e7 ASSESSOR'S INFORMATION: Map: /� Parcel: OWNER: ve avi V 1 tl�'.rc.1 Z 7 (0-1-ail fJU1f �� t fL/No,)fL Wig C�26�1 NAME )� PRESENT ADDRESS TEL. # CONTRACTOR: l r rl f�t 'r-S,5:11 5 6/ La iv,- ail,i- V 2(1 � ecti/w� NAME MAILING ADDRESS TEL.# _Coe- ?`j U ??O 49) yi Residential 0 Commercial Est.Cost of Construction$ / (f S Uv Home Improvement Contractor Lic.# I Li 30 S 3 Construction Supervisor Lic.# 94 . .f/ Workman's Compensation Insurance: (check one) 0 I am the homeowner 0 I am the sole proprietor IJ I have Worker's Compensation Insurance Insurance Company Name: (1 v /4 Worker's Comp.Policy# (S 5,-;✓a p Z Z le/L 17 2 2Z WORK TO BE PERFORMED Tent 1=1 Duration (Fire Retardant Certificate attached?) Wood Stove 0 Siding:_#of Squares Replacement windows:# Replacement doors: # Roofingf Squares 5 (E1)Remove existing*(max.2 layers) Insulation I I `I Old Kings Highway/Historic Dist. ()Replacing like for like Pool fencing n *The debris will be disposed of at: Y 6 f/14(jv /-1- v vl Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s) will be just cause for denial or rev • of my license and for prosecution under M.G.L.Ch.268,Section 1. Applicant's Signature: Date: / /((61? 2-- Owners Signature(or attachment) Date: / / Approved By: ' '�/ Date: // / ' Building Official(or designee . EMAIL ADDRESS: Zoning District: Historical District: ❑ Yes ❑ No Flood Plain Zone: ❑ Yes ❑ No Water Resource Protection District: Within 100 ft.of Wetlands: 0 Yes 0 No ❑ Yes 0 No < r trti _ i,d �LTI . Itt$1,Act , 1(.11 ! Mil r't_i '4Z3 VtI 1ls.�gy,.•itir �i v�i4, 4te 3'izts+ if1i�€ }} 3 jam ., 'U.! 4 .c -'jFjiy'p`":JG, "�c R�3;t ,": >4.� `tee) `i::J 'tfLrlS�' t...,, 'c r . - '; r ..-' . .r. .... it74.• .tlfb ..Hit;:;;;fi: t ll++ gar tr. ;,".; #t al3;n:l; a:a . 4�~. . ; ._.. '�. tt qf} z • ;;),.• •,.:4(,E,D ; Rest' t , si:t ,7r�3 ;rr, rigttr. 1. ate • -1!r,'t:.i.:f3tt ny;i' -.r1 •4: J r� ,.. The Commonwealth of Massachusetts I =_,ii- Department oflndustrialAccidents t _= 1 Congress Street, Suite 100 0 =')��= Boston, M4 02114-2017 ; www mass.gov/dia \Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE RILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): ire e, 1 Ai Address: Sir L-Urger gro4.)21 f? City/State/Zip: } c,11 v k titif O 26 y Phone#: -SO 76 c) (-76) ' Are you an employer?Check the appropriate box: Type of project(required): l:nI am a employer with / employees(full and/or part-time).* 7. New construction 2.01 am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8. Remodeling 3.01 am a homeowner doing all work myself. [No workers'comp.insurance required.]t 9. ❑Demolition 401 am a homeowner and will be hiring contractors to conduct all work cn my property. I will 10[]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.QElectrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions 5.11I am a general contractor and I have hired the sub-contractors listed or the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 13•El Roof repairs 6.1=1We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees. [No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: tl 4 Policy#or Self-ins.Lic.#: SS tc,ryd I2 c.r2 7 ?.2 Expiration Date: 3/ / 2_3 Job Site Address: Z (40/z i00 re et) City/State/Zip: 1/l, :°i #22-4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify un er the pains and penalties of perjury that the information provided above is true and correct Si nature: Date: ////Z/ 22 Phone#: S 0 r 7C0 2 7U z Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: _______ -- „ ------.. ,_ . . ____„___.... ,• 7 , / ,'' • ., •Alsz'aiik‘.:),-.. ,•••::-.r,';,,:•,) !VI\':,,..,k4',.t.'-7t1-( i'4'7•2;) 314:".$ ,7.7.7„.._.-71-.1...4C-:::.". -,,,. ‘':2.;,:i!rt,'11 ,1".ti•-\.4 t 1 M..4 iAl":'''',,r.`: --:,4 ,_•34.,,.,„'L' .7•-_-..:--,- ‘31t.',.. 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'-::-.7:":":::-.:1.."r-;:"-.7 '..""::"*".'.:“"..-...--, Keating Construction Home improvement contractor registration: 143053 DATE October 1, 2022 54 Lower Brook Rd Quotation# 1 So_ Yarmouth MA 02664 Phone(508) 760 2702 timkeating66Ca7hotmail rpm Proposal for: Sue Murray Job name/location: 29 Captain Dore Rd Same Yarmouth Ma 02664 508 243 2683 We Nearby submit s ificatons and Strip roof shingles off entire house Install water and ice shield on lower edges and chimneys Install new vent pipe flanges and 30 lb tar paper on decking Inctail naw tA/hita R inrh rfrin Prim Install Certainteed Landmark 30 yr architectural shingles Install ridge vent at all peaks All debris and trash will be removed and disposed of properly Only items specified above are included in this proposal. Chimney flashing replacement is not included in this proposal Rotted wood repair is not included in this proposal $35.00 per hr + materials if needed Materials guaranteed by manufacturers. Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: $11,500.00 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: Date of acceptance: Acceptance of Proposal: Date of acceptance: The above prices. specification an n lion satisfactory and are hereby accepted. '4cw CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. H S, CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorst if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement or this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME. JIM HINDMAN _ Schlegel&Schlegel Ins Broker PHONE 508-771$381 34 Main Street �° Eie1 11Atc,No): 508-771-066 West Yarmouth, MA 02673 ADDRESS: schiegei{nsuranceeQmai{.com INSURER(S)AFFORDING COVERAGE NA I INSURER A: MOUNT VERNON INSURED I INSURER 8: CNA TIMOTHY KEATING DBA KEATING I INSURER C: CONSTRUCTION 54 LOWER BROOK RD INSURER D SOUTH YARMOUTH, MA 02664 I INSURER E: LINSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MA'(HAVE BEEN REDUCED BY PAID CLAIMS. INSR (MOro�Y EFF POLICY EXP LTR TYPE OF INSURANCE I WVD POLICY NUMBER /YYYY)JM1O0JYYYY) UNITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,0 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence; S 5 MED EXP(Any one Person) S A __. NN 12325470 03119/22 03N9/23 PERSONAL&ADV INJURY S 1,0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,0 POLICY n 787 LOC PRODUCTS-COMP/OP AGG S 2,0 I OTHER S AUTOMOBILE UAeILrnY COMBINED SINGLE LIMIT $ (Ea acckientl ANY AUTO BODILY INJURY(Per person! S } OWNED SCHEDULED AUTOS ONLY _- AUTOS BODILY INJURY(Per accident) S 1,1 HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY I (Per am dent) S S UMBRELLA UAB OCCUR EACH OCCURRENCE jS 1 EXCESS UAt! CLAIMS-MADE i I AGGREGATE $ 1 DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETORIARTNERIEXECUTIVE B OFFICERIMEMBER EXCLUDED? N N/A 6S59UB0224N37222 03/09/22 03/09/23 E.L.EACH ACCIDENT S 1! Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 11 If yyeess describe under DESCRIPTION OF UF'ERATIONS below EL.DISEASE-POLICY LIMIT S 51 I 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS,EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEF THE EXPIRATION DATE THEREOF,NOTICE WILL BE DEUVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT YARMOUTH MA AUTHORIZED REPRESENT I © 8-2015 ACORD CORPORATION. Ali rinhta rocs ty.t.t.*„: , i - .,•"'41.44.ti ti--,,4 4A 4 `. 'e', '...., -''''''.-714.4"' *Or - ' i - , . .--i*' 3- 74'H .2.71kli;I:7.'f.7'46''.4';.1' '''.;.r.7:''. '::F.4 /#1- 'e-,',..,',i i,- 4. '1 .::lr''..,:*--Tf!1;47ii7;0-- '. 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'-1, ':',.::;',.''' .:- ,.",' , •- ' ' '," i,:,:il,"..-."....i .i' . . .,, - ' • '' ..i... ,-. i :' r OH - ) :- i., '',":"7 4, : „ . -.....,—,,-- --- —.— t A '' As ii!=,'L` " 4,: ...,:' :;'1, ".•, `'" t • 1 Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards ,CcnstructietietY4 /is�tr Specialty tiela�oas�apu� t99Z0 yW'Hl(lOWatl l'OS •Qa NOOd9 t13MO1 t9 CSSL-099351 = ,;w Ekpires:05/11/2022 a �JNllt/3N 9J.HlOW11 TIM B KEATING 54 LOWER BROOK ROAD •1SNOO ONI AH `d/9/O SOUTH YARMOUTH MA 02664 i 4 � DNI1V3N.lHlOW11 ZZOZ/£L/90 £SO£t L t ) 1 r` uolte.nd y x3 uoge.�tslba(S'4 11 en w u I P. .P 13dl�l /s t1Oi3Va1NOO 1N3 W3AOlid Wl 3 WOH Commissioner jRs? bier/mita uoneln6au ssawsne'g sJle}fy.iawnsuo3}o aogio Demographic Information !Full Name: _ Tim B Keating K wner Name: License Address Information City: South Yarmouth State: MA Ripcode: 02664 Country: United States I_iceiise In for rnatioo License No: CSSL-099351 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 5/24/2022 Issue Date: 6/4/2008 Expiration Date: 5/11/2024 License Status: Active Today's Date: 7/25/2022 Secondary License Type: Doing Business As: ____] Status Change Reason: License Renewal Prerequisite Information Licensee: Keating, Tim B �R Relationship: Attribute Of License No: CSSL-099351 Licensee: Keating, Tim B Relationship: Attribute Of License No: CSSL-099351 No Available Documents THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation 1000 Washington Street - Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration TIMOTHY KEATING Type: Individual Registration: 143053 D/B/A KEATING CONSTRUCTION Expiration: 06/13/2024 54 LOWER BROOK RD. SO.YARMOUTH, MA 02664 Update Address and Return Card. THE COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only before the HOME IMPROVEMENT CONTRACTOR expiration date. If found return to: TYPE:Individual Office of Consumer Affairs and Business Regulation Rogiplation Expiration 1000 Washington Street -Suite 710 143053 06/13/2024 Boston,MA 02118 VIOTHY KEATING 3/A KEATING CONSTRUCTION AOTHY B.KEATING LOWER BROOK RD. .YARMOUTH,MA 02664 c�,,,,,�`i Undersecretary Not valid without signature